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Efficacy of cognitive behavioural therapy for bipolar disorder: A systematic

review

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DOI: 10.1016/j.rcpeng.2021.05.009

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 ARTICLE IN PRESS
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www.elsevier.es/rcp

Original article

Efficacy of cognitive behavioural therapy for bipolar

disorder: A systematic review

Glauco Valdivieso-Jiménez a,b,∗

a Instituto Peruano para el Estudio y Abordaje Integral de la Personalidad, Lima, Peru
b Servicio de Psiquiatría, Hospital de Emergencias Villa El Salvador, Lima, Peru

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Bipolar disorder (BD) is a serious mental illness with a chronic course and
Received 18 February 2021 significant morbidity and mortality. BD has a lifetime prevalence rate of 1%–1.5% and is
Accepted 19 May 2021 characterised by recurrent episodes of mania and depression, or a mixture of both phases.
Available online xxx Although it has harmacological and psychotherapeutic treatment, cognitive behavioural
therapy (CBT) has shown beneficial effects, but there is not enough clinical information in
Keywords: the current literature.
Bipolar disorder Methods: The main aim was to determine the efficacy of CBT alone or as an adjunct to
Cognitive behavioural therapy pharmacological treatment for BD. A systematic review of 17 articles was carried out. The
Efficacy inclusion criteria were: quantitative or qualitative research aimed at examining the efficacy
of CBT in BD patients with/without medication; publications in English language; and) being
18–65 years of age. The exclusion criteria were: review and meta-analysis articles; articles
that included patients with other diagnoses in addition to BD and that did not separate the
results based on such diagnoses; and studies with patients who did not meet the DSM or
ICD criteria for BD. The PubMed, PsycINFO and Web of Science databases were searched up
to 5 January 2020. The search strategy was: “Bipolar Disorder” AND “Cognitive Behavioral
Therapy”.
Results: A total of 1531 patients both sexes were included. The weighted mean age was 40.703
years. The number of sessions ranged from 8 to 30, with a total duration of 45–120 min. All
the studies show variable results in improving the level of depression and the severity of
mania, improving functionality, reducing relapses and recurrences, and reducing anxiety
levels and the severity of insomnia.
Conclusions: The use of CBT alone or adjunctive therapy in BD patients is considered to show
promising results after treatment and during follow-up. Benefits include reduced levels of
depression and mania, fewer relapses and recurrences, and higher levels of psychosocial
functioning. More studies are needed.
© 2021 Asociación Colombiana de Psiquiatrı́a. Published by Elsevier España, S.L.U. All
rights reserved.

DOI of original article: https://doi.org/10.1016/j.rcp.2021.05.006.

∗
Corresponding author.
E-mail address: glauco.valdivieso@unmsm.edu.pe
2530-3120/© 2021 Asociación Colombiana de Psiquiatrı́a. Published by Elsevier España, S.L.U. All rights reserved.

RCPENG-461; No. of Pages 10

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Eficacia de la Terapia Cognitiva Conductual Para el Trastorno Bipolar: una

Revisión Sistemática

r e s u m e n

Palabras clave: Introducción: El trastorno bipolar (TB) es una enfermedad mental grave con un curso crónico
Trastorno bipolar y una morbimortalidad importante. El TB tiene una tasa de prevalencia a lo largo de la vida
Terapia cognitiva conductual del 1 al 1,5% y se caracteriza por episodios recurrentes de manía, depresión o una mezcla
Eficacia de ambas fases. Aunque tiene tratamiento farmacológico y psicoterapéutico, la terapia cog-
nitiva conductual (TCC) ha mostrado efectos beneficiosos, pero no se cuenta con suficiente
información clínica en la literatura actual.
Métodos: El objetivo principal es determinar la eficacia de la TCC sola o como complemento
del tratamiento farmacológico para el TB. Se realizó una revisión sistemática de 17 artículos.
Los criterios de inclusión fueron: investigación cuantitativa o cualitativa dirigida a examinar
la eficacia de la TCC en pacientes con TB con/sin medicación, publicaciones en idioma
inglés y tener 18–65 años de edad. Los criterios de exclusión fueron: artículos de revisión y
metanálisis, artículos que incluían a pacientes con otros diagnósticos además de TB y no
separaban los resultados basados en dichos diagnósticos y estudios con pacientes que no
cumplían los criterios de TB del DSM o ICD. Se realizaron búsquedas en las bases de datos
PubMed, PsycINFO y Web of Science hasta el 5 de enero de 2020. La estrategia de búsqueda
fue: “Bipolar Disorder” AND “Cognitive Behavioral Therapy”.
Resultados: Se incluyó en total a 1.531 pacientes de ambos sexos. La media de edad pon-
derada fue 40,703 años. El número de sesiones varió de 8 a 30, con una duración total de
45–120 min. Todos los estudios muestran resultados variables en la mejora del nivel de
depresión y la gravedad de la manía, mejora de la funcionalidad, disminución de recaí-
das y recurrencias, reducción de los niveles de ansiedad y reducción de la gravedad del
insomnio.
Conclusiones: Se considera que la TCC sola o complementaria para pacientes con TB muestra
resultados prometedores después del tratamiento y durante el seguimiento. Los beneficios
incluyen niveles reducidos de depresión y manía, menos recaídas y recurrencias y niveles
más altos de funcionamiento psicosocial. Se necesitan más estudios.
© 2021 Asociación Colombiana de Psiquiatrı́a. Publicado por Elsevier España, S.L.U.
Todos los derechos reservados.

chotherapy are more effective in treating patients with BD

Introduction
than medication alone.8
As an adjuvant treatment, psychotherapy helps patients
Bipolar disorder (BD) is a severe mental illness with a chronic
with BD improve treatment adherence, illness awareness and
course and significant morbidity and mortality rates. BD has
coping skills for problematic life events, collectively resulting
a lifetime prevalence rate of 1%–1.5% and is characterised
in a better response to psychotropic medications. Among the
by recurrent episodes of mania, depression, or a mixture
psychosocial therapies that are potential adjuncts to medica-
of the two phases.1,2 BD causes cognitive symptoms, func-
tions for patients with BD, cognitive behavioural therapy (CBT)
tional impairment and poor physical health and is associated
is a promising treatment option. However, it has inconclu-
with a high rate of suicidal behaviour. These patients have
sive findings due to the lack of large study samples and their
difficulties with interpersonal relationships due to the dra-
heterogeneity.9
matic alternation of manic, hypomanic and depressive mood
Randomised controlled trials (RCT) published in the last
cycles.3–5
10 years have revealed the potential benefits of CBT as an
A cohort study with a large sample size (n = 1469) showed
adjunct to mood stabilisers for preventing relapse, alleviat-
that 58% of patients with BD types I and II recovered, but
ing symptoms and improving medication adherence.10 Some
approximately half of them suffered a recurrence within two
meta-analyses have recently evaluated the effectiveness of
years.6 This severe mood disorder affects Millions of patients
CBT for BD. These studies have shown that CBT has a negli-
worldwide, costing thousands of dollars for years of living with
gible impact on clinical symptoms, but the evidence remains
a disability.7
limited.11,12
It has been proven that there is a consistent biological basis
In this study, we analysed research on the effectiveness
in the development of the disease, which is why psychotropic
of CBT alone or adjuvant to medications for the treatment of
drugs are the first-line treatment. However, a growing body
BD to guide mental health professionals in making evidence-
of literature indicates that combined drug therapy and psy-
based decisions for treating these patients.
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Methods
To achieve the objectives of this review, we followed the recom-
mendations of the Preferred Reporting Items for Systematic
Review and Meta-Analysis Protocols (PRISMA-P) model by
Moher et al.13
Selection criteria for studies
The inclusion criteria for the studies were: quantitative or
qualitative research aimed at examining the effectiveness of
CBT in patients with BD with or without medication, publica-
tions in English, and ages between 18 and 65. The exclusion
criteria were: review and meta-analysis articles, articles that
included patients with diagnoses other than BD that did not
separate the results based on such diagnoses, and studies with
patients who did not meet the DSM or ICD criteria for BD.
Search strategy
Searches were made in the PubMed, PsycINFO, and Web of Sci-
ence databases up to 5 January 2020. The search strategy used
in each of these databases was as follows: “Bipolar Disorder”
AND “Cognitive Behavioral Therapy”. The filters applied in the
three databases allowed the inclusion criteria to be met.
Study selection process
This process was carried out in four phases. First (article
identification phase), the results of the searches in the three
databases were unified and duplicate articles were eliminated.
Second (screening phase), we read the titles and abstracts of
the articles that potentially met the inclusion criteria. If there
were doubts, we reviewed the full text of the questioned arti-
cle. Third (eligibility phase), the full-text articles preselected in
the previous phase and the questioned articles were examined
and read independently. Finally (inclusion phase), we decided
to select the articles included in this systematic review.
Data extraction process for each study
The following information was extracted from the selected
articles: study title; author(s) and year of publication; size
of the patient sample; characteristics of the participants
(sociodemographic data, diagnosis, whether they were outpa-
tients or hospitalised and phase of the disease at the time of
BD evaluation); study characteristics (methodology, duration
and existence of a control group); type of treatment received
by patients; characteristics of the intervention (number of
sessions, duration of treatment, group size and professional
certification); variables and measurement instruments; and
results with mention of statistical significance. The results
were classified into primary variables (depressive symptoms
and mania), those that reflect the most critical symptoms
which were expected in all the included studies, and sec-
ondary variables (functioning, relapses/recurrences, level of
anxiety and insomnia), which were those associated with
other clinical characteristics not considered in all the stud-
ies.
3
Results
Main demographic characteristics
We selected 17 original studies which met the inclusion crite-
ria. Fig. 1 shows the selection process for these articles. Their
main characteristics are set out in Table 1. The selected studies
included a total of 1531 patients. All of them were outpatients.
Based on the available data (17 articles), the weighted mean
age of the patients was 40.703 years. We can see that the stud-
ies were carried out in seven different countries, distributed as
follows: United States (4 studies); United Kingdom (3 studies);
Spain (3 studies); Brazil (3 studies); Canada (2 studies); France
(1 study); and Germany (1 study). All the studies included were
randomised controlled trials (RCT). Most included single CBT
interventions compared to a standard BD intervention control
group. However, in five studies, CBT was an adjunct to other
interventions such as psychoeducation (PE), family-focused
therapy (FFT), and interpersonal and social rhythm therapy
(IPSRT) and included as part of intensive psychosocial treat-
ment (IPT) in two of these studies.
The diagnoses of BD I and BD II were considered in 14 stud-
ies, while three only included patients with BD I.
In 12 studies, female patients outnumbered male patients,
with males predominating in only two; in one, the gender dis-
tribution was equal, and in another, it was unclear because it
was not detailed in the article’s content.
Regarding the intervention, the number of sessions varied
from 8 to 30, with a total duration of 45–120 min. In 11 studies,
CBT was performed in individual mode, while in six, it was in
group mode. In all 17 studies, a certified professional carried
out the single and adjunctive CBT interventions.
Primary variables
Depressive symptoms and mania
In 15 of the studies, the level of depression and severity of
mania were assessed; in 2, only the level of depression was
assessed (Stange, 2013; Miklowitz, 2007). With regard to the
effectiveness in the CBT groups, all studies show improve-
ments in the scores of the instruments applied for level of
depression and severity of mania, but nine of the 17 studies
did not show statistical significance in the clinical assessment
after the treatment. In four of the 17 studies, statistical signifi-
cance was shown in both variables (Parrikh, 2013; Costa, 2012;
Costa, 2011; Gonzalez-Isasi, 2010). In two of the 17, partial sig-
nificance was shown, in one for mania but not for depression
and in the other, vice versa.
Secondary variables
Functioning
In eight studies, functioning was seen to improve (Harvey,
2015; Jones, 2015; Parrikh, 2013; Meyer, 2012; Gonzalez-Isasi,
2010; Zaretsky, 2008; Miklowitz, 2007; Lam, 2000). However,
that improvement was only statistically significant in one (Par-
rikh, 2013). Many of these studies also measured quality of life
and maladjustment, so it is specified that the assessment of
these variables is different from functioning. The instruments
 4
Table 1 – Characteristics of the studies selected.
Study Country Intervention Design Sample size Intervention Variables and Results and
(author, year) (experimental vs characteristics evaluation significance
control) instruments

Harvey et al.14 United States CBT/PE RCT N = 58 No. of sessions, 8 Relapse rate (episodes) Relapse rate NSS
(2015) Complete (E/C), 30/28 Duration of treatment, 50–60 min Insomnia (ISI, SD-SE, PSQI)
Mean age, 36.6 Group size (people): individual Depression level (IDS-C)
Males/females, 22/36 CBT therapist: certified Mania severity (YMRS)
BD I, 58 professional Functioning (SDS)
Time points evaluated
(months): post-treatment, Insomnia SS
6-month follow-up Depression level NSS
Severity of mania SS
Functioning NSS

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Jones et al.15 United CBT/UT RCT N = 67 No. of sessions, 24 Depression level (HRDS) Depression level NSS

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(2015) Kingdom Complete (E/C), 33/34 Duration of treatment, 45−60 min Mania Severity (MAS)
Mean age, 36.6 Group size (people): individual Social functioning (PSP)
Males/females, 0/67 CBT therapist: mental Quality of life (QoLBD)
BD I, 53 health professional Time points evaluated:
BD II, 14 post-treatment, 6 and 12
months Severity of mania SS
Functioning NSS
Quality of life NSS
González Spain CBT + PE + FFT RCT N = 40 No. of sessions, 20 Relapse Relapse NSS
Isasi et al.16 Complete (E/C), 20/20 Duration of treatment, 90 min Depression level (BDI)
(2014) Mean age, 41.3 Group size (people), 10 Mania Severity (YMRS)
Males/females, 21/19 CBT therapist: certified Anxiety level (STAI-S)
BD I/II, 40 professional Maladjustment Scale (IS)
Refractory BD Time points evaluated: 6, 12
and 60 months Depression level SS
Severity of mania NSS
Anxiety level SS
Maladjustment SS
Parrikh Canada CBT/PE RCT N = 119 No. of sessions, 20 Depression level (HRDS) Depression level SS
et al.17 (2013) Complete (E/C), No Duration of treatment, 50 min Severity of mania (CARS-M)
Mean age, 42.3 Group size (people): individual Functioning (GAF)
Males/females, 49/70 CBT therapist: not stated Time points evaluated:
BD I, 87 post-treatment, 18 and 72
BD II, 32 months
Severity of mania SS
Functioning SS
Stange et al.18 United States CBT + IPSRT + RCT N = 106 No. of sessions, 30 Depression level (CMF, ASQ) Depression level NSS
(2013) FFT/UT Complete (E/C), 31/44 Duration of treatment, 50 min Time points evaluated:
Mean age, 39.6 Group size (people): individual post-treatment
Males/females, 41/65 CBT therapist: certified
BD I, 64 professional
BD II, 42
– Table 1 (Continued)
Study Country Intervention Design Sample size Intervention Variables and Results and
(author, year) (experimental vs characteristics evaluation significance
control) instruments

Docteur France CBT + FFT RCT N = 73 No. of sessions: not stated Depression level (HDRS) Depression level SS
et al.19 (2013) Complete (E/C), 53/20 Duration of treatment: not stated Mania severity (MRS)
Mean age, 45.24 Group size (people): individual Anxiety level (HARS)
Males/females, 28/45 CBT therapist: not stated Time points evaluated:
BD I, 73 post-treatment, 6 and
12-month follow-up Severity of mania NSS
Anxiety level SS
Meyer and Germany CBT/UT RCT N = 76 No. of sessions, 20 Recurrence rate Recurrence NSS

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Hautzinger 20 Complete (E/C), 38/38 Duration of treatment, 50–60 min Depression level (BDI)
(2012) Mean age, 44 Group size (people): individual Severity of mania (SRMI)
Males/females, 38/38 CBT therapist: certified Functioning (GAS)
BD I, 38 therapist Time points evaluated:
BD II, 38 post-treatment
Depression level NSS
Severity of mania NSS
Functioning NSS
Costa et al.21 Brazil CBT/UT RCT N = 39 No. of sessions, 14 Depression level (BDI) Depression level SS
(2012) Complete (E/C), 27/12 Duration of treatment, 120 min Mania severity (YMRS)
Mean age, 41.5 Group size (people): group Quality of life (SF-36)
Males/females, 12/25 CBT therapist: certified therapist Time points evaluated: 7, 14
months
BD I/II, 39
Severity of mania SS
Quality of life SS
Costa et al.22 Brazil CBT/UT RCT N = 41 No. of sessions, 14 Depression level (BDI) Depression level SS
(2011) Complete (E/C), 27/12 Duration of treatment, 120 min Mania severity (BHS)
Mean age, 40.5 Group size (people): group Anxiety level (BAI)
Males/females, 12/25 CBT therapist: certified Time points evaluated: 7, 14
BD I, 35 therapist months
BD II, 6
Severity of mania SS
Anxiety level SS
Gomes Brazil CBT/UT RCT N = 50 No. of sessions, 18 Depression level (HDRS) Depression level NSS
et al.23 (2011) Complete (E/C), 25/22 Duration of treatment, 90 min Mania Severity (YMRS)
Mean age, 38 Group size (people): 4.4 Time points evaluated:
Males/females, 12/38 CBT therapist: certified therapist post-treatment, 6 months
BD I, 38
BD II, 12
Severity of mania NSS

5
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– Table 1 (Continued)
Study Country Intervention Design Sample size Intervention Variables and Results and
(author, year) (experimental vs characteristics evaluation significance
control) instruments

González- Spain CBT + PE + FFT RCT N = 40 No. of sessions, 20 Relapse Relapse SS

Isasi et al.24 Complete (E/C), 20/20 Duration of treatment, 90 min Depression level (BDI)
(2010) Mean age, 41.3 Group size (people): 10 Mania severity (YMRS)
Males/females, 21/19 CBT therapist: certified Anxiety level (STAI-S)
BD I/II, 40 professional Time points evaluated:

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post-treatment, 6 and Depression level SS
12-month follow-up Severity of mania SS
Anxiety level SS
González- Spain CBT/CS RCT N = 20 No. of sessions, 13 Relapse Relapse NSS
Isasi et al.25 Complete (E/C), 20/20 Duration of treatment, 90 min Depression level (BDI)
(2010) Mean age, 38.5 Group size (people): 10 Mania severity (YMRS)
Males/females, 6/14 CBT therapist: certified professional Functioning (GAF)
BD I/II, 40 Time points evaluated:
post-treatment, 6 and Depression level NSS
12-month follow-up Severity of mania NSS
Functioning NSS
Zaretsky Canada CBT/PE RCT N = 79 No. of sessions, 14 Depression level (HDRS) Depression level NSS
et al.26 (2008) Complete (E/C), 29/24 Duration of treatment: not stated Severity of mania (CARS-M)
Mean age, 40.7 Group size (people): individual Functioning (DAS)
Males/females, not CBT therapist: certified Time points evaluated: 2, 6,
stated professional 12 months
BD I, 52
BD II, 27
Severity of mania NSS
Functioning NSS
Miklowitz United States CBT(IPT)/CB RCT N = 152 No. of sessions, 30 Depression level (MADRS) Depression level NSS
et al.27 (2007) Complete (E/C), 84/68 Duration of treatment, 60 min Functioning (LIFE-RIFT)
Mean age, 41.1 Group size (people): individual Time points evaluated: 3, 6
Males/females, 64/88 CBT therapist: not stated and 9 months
BD I, 105
BD II, 47
Functioning NSS
– Table 1 (Continued)
Study Country Intervention Design Sample size Intervention Variables and Results and
(author, year) (experimental vs characteristics evaluation significance
control) instruments

Miklowitz United States CBT(IPT)/CB RCT N = 293 No. of sessions, 30 Depression level (MADRS) Depression level NSS
et al.28 (2007) Complete (E/C), 163/130 Duration of treatment, 50 min Mania severity (YMRS)
Mean age, 40.1 Group size (people): individual Time points evaluated: 12
Males/females, 120/173 CBT therapist: certified months
BD I, 197 professional

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BD II, 90
BD-NS, 5
Severity of mania NSS
Scott et al.29 United CBT/CS RCT N = 253 No. of sessions, 22 Recurrence rate (episodes) Recurrence NSS
(2006) Kingdom Complete (E/C), 127/126 Duration of treatment: not stated Depression level (LIFE II)
Mean age, 41.2 Group size (people): individual Severity of mania (LIFE II)
Males/females, 89/164 CBT therapist: certified Time points evaluated: 6, 12
BD I, 238 professional and 18 months
BD II, 15
Depression level NSS
Severity of mania NSS
Lam et al.30 United CBT/UT RCT N = 25 No. of sessions, 12−20 Depression level (BDI, BHS, Depression level NSS
(2000) Kingdom HDRS)
Complete (E/C), 12/11 Duration of treatment: not stated Mania severity (MRS)
Mean age, 39 Group size (people): individual Functioning (SPS)
Males/females, 12/13 CBT therapist: certified Time points evaluated: 6
BD I, 25 professional and 12 months
Severity of mania NSS
Functioning NSS

ASQ: attributional style questionnaire; BAI: Beck Anxiety Inventory; BDI: Beck’s Depression Index; BHS: Beck Hopelessness Scale; CARS-M: clinician-administered rating scale for mania; CBT: cognitive-
behavioural therapy; CMF: clinical monitoring form; DAS: dysfunctional attitude scale; FFT: family-focused treatment; GAF: global assessment of functioning; GAS: global assessment scale; HARS:
Hamilton Anxiety Rating Scale; HRSD: Hamilton Rating Scale for Depression; IDS-C: inventory of depressive symptomatology, clinician rating; IPSRT: interpersonal and social rhythm therapy; IS:
maladjustment scale; ISI: insomnia severity index; LIFE II: longitudinal interval follow-up evaluation; LIFE-RIFT: longitudinal interval follow-up evaluation–range of impaired functioning tool; MAS:
Bech–Rafaelsen Mania Scale; NS: not specified; NS: not significant; PE: psychoeducation; PSP: personal and social functioning scale; PSQI: Pittsburgh Sleep Quality Index; QoL BD: brief quality of life in
bipolar disorder questionnaire; RCT: randomised clinical trial; SDS: Sheehan Disability Scale; SD-SE: sleep daily sleep efficiency; SS: statistical significance; SRMI: self rating mania inventory; STAI-S:
state trait anxiety inventory; UT: usual treatment; YMRS: Young Mania Rating Scale.

7
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Records identified through Additional records identified

Identification
database search through other sources
(n = 71) (n = 0)

Records after eliminating duplicates

(n = 71)
Screening

Records examined Records excluded

(n = 71) (n = 40)

Full-text articles
excluded, with reasons
(n = 14)
Full-text articles 10 Do not separate
Eligibility

evaluated for the results according

eligibility to diagnosis.
(n = 31) 2 Duplicate results
2 Do not measure BD
Included

Studies included in
qualitative summary
(n = 17)

Fig. 1 – PRISMA flow diagram illustrating the article selection process for the systematic review.
Records identified by database search (n = 71).

used to assess functioning were varied: DAS, PSP, GAF, SDS,
GAS and LIFE-RIFT.
Relapses and recurrences
Six of the 17 studies (Harvey, 2015; Gonzalez-Isasi, 2014; Meyer,
2012; Gonzalez-Isasi, 2010; Gonzalez-Isasi, 2010; Scott, 2006)
evaluated the relapse/recurrence rates, measured in several
hospitalisations or clinical worsening, in which there was a
decrease in these values. However, only one showed statisti-
cal significance (Gonzales-Isasi, 2010). In three studies, relapse
was considered as clinical worsening during the episode of ill-
ness and follow-up according to the established time points. In
contrast, recurrences during follow-up were considered when
significant clinical improvement had already been achieved,
and clinical decline led to hospitalisation. The measure-
ment of this variable was objective and tangible, quantified
as episodes, so it did not require longitudinal psychometric
scores, which explains why all authors do not share this cri-
terion.
Anxiety level
In four of the studies, CBT, compared to the usual treat-
ment, achieved a statistically significant reduction in anxiety
levels when applying the STAI-S, HARS and BAI instru-
ments (Gonzalez-Isasi, 2014; Docteur, 2013; Costa, 2011;
Gonzalez-Isasi, 2010). The instruments are varied. Neither the
predominant affective phase of the patients nor whether it
was BD I or II was specified. This is important, as anxiety
occurs with much greater intensity in manic states and sub-
syndromal states.
Insomnia
Only in one study (Harvey, 2015) in which CBT and PE were
compared significant reductions in insomnia severity were
achieved six months after treatment using the ISI, SD-SE and
PSQI instruments. Although insomnia was measured in only
one study with different instruments, significant differences
were obtained with the treatment of BDĨ, coinciding with
improvement in I, coinciding with improvement in the levels
of depression, anxiety and mania. The predominant condition
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of the patients at the time of measurement was not specified;
this would be important, as insomnia is considered a cardi-
nal symptom of mania/hypomania and depression levels are
measured simultaneously.
Discussion
In this review, we analysed 17 RCTs, which compared treat-
ment results using CBT alone or adjuvant to drug therapy
to usual treatment for patients diagnosed with BD. Primary
variables were assessed, such as relapse/recurrence, level of
depression, severity of mania, level of anxiety, insomnia and
functioning. The role of antidepressants in influencing effec-
tiveness outcomes has not been clearly determined.
CBT positively influenced the outcomes in terms of levels of
depression and mania considered in 15 studies in our review.
Out of all of them, despite the improvements in the scores,
the clinical improvement in BD I and II was only statistically
significant in six. These findings are consistent with those
of Chiang.31 Despite including studies of the application of
CBT alone and adjuvant to other treatments for BD, the meta-
analysis indicates a mild-to-moderate effect size in reducing
the rate of relapses and manic-depressive symptoms, espe-
cially in patients with BD I. The assessment instruments were
varied, which reduces the clarity of the outcome but is help-
ful to compare our findings. In their systematic review, Oud
et al.33 report that CBT reduces depressive and manic symp-
toms, hospital readmissions and relapses, which is also in line
with our study. In contrast, Chatterton et al.32 conclude that
neither CBT alone nor combined with PE generate significant
reductions in depressive symptoms in any of their studies
despite measuring scale scores at different post-treatment
time points. However, PE alone, combined with CBT, showed a
significant reduction in manic symptoms associated with lack
of adherence to treatment and lower relative risk. Across the
12 studies of PE by Chatterton et al., the variables studied are
limited and different, so there needs to be more clarity as to
why the results differ from those of CBT. These authors finally
point out that the combination of both treatments offers bet-
ter overall results, as does da Costa et al.,34 who include in
their findings a better quality of life, as well as a reduction
in depressive and manic symptoms. Ye et al.11 show that
CBT significantly reduces the severity of manic symptoms and
relapses, but not depressive symptoms, at different measure-
ment time points.
Functioning, as a secondary variable, shows clinical
improvement with CBT but is not statistically significant in
all studies. As in the other variables, the psychometric instru-
ments were different, and the operationalisation given to
functioning is confusing, as this could be considered the
quality of life and maladjustment, so we have attempted
to separate and avoid biases in the analysis. Our study’s
improvement in functioning scores coincided with the lev-
els of depression and severity of mania in BD I and BD II.
These findings are compatible with Chatterton et al., who
consider that the coinciding of improvement in mania and
global functioning with CBT alone and in combination indi-
cates increasing effectiveness over time, with more benefits
in patients with BD I.
9
The level of anxiety and insomnia were variables little
studied. They much less discussed in previous systematic
reviews, as the results reflect significant reductions in mania,
depression, number of relapses and functioning. This is likely
because few reviews and meta-analyses include studies based
on secondary variables, and anxiety and insomnia are consid-
ered to underlie measures of depression and anxiety. These
differences are not discussed in other studies.
The limitations lie in the heterogeneity of the sample par-
ticipants in the included studies and the small number of
studies carried out to date that only compare CBT with stan-
dard psychopharmacological treatment and the combination
of the two. During the search for information, we found that
other systematic reviews and meta-analyses include interven-
tions that do not follow the basis of pure CBT, such as MBCT
(Mindfulness Based Cognitive Therapy), CT (Cognitive Therapy) and
PE, and the objectivity and quality of the study are lost, which
biases our results. It is necessary to expand the number of RCT
with a greater number of participants.
Conclusions
CBT alone or as an adjunct for BD patients shows promising
results after treatment and during follow-up. Benefits include
reduced levels of depression and mania, fewer relapses and
recurrences, and increased levels of psychosocial functioning.
Additional studies should investigate optimal patient selec-
tion strategies to maximise the benefits of CBT as an adjunct.
Funding
The author declares self-financing.
Conflicts of interest
The author has no conflicts of interest to declare.
Acknowledgements
Special thanks for advising on this study to Dr Nelson Andrade
of the Alcalá de Henares University, Madrid, Spain.
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